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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35876/psn-pdfJune 18, 2013 - External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001. June 18, 2013 Toft B. London, UK; Crown Copyright: 2001. https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham- 4th-january-2001 This UK Department o… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45048/psn-pdfApril 13, 2016 - Do not let "Depo-" medications be a depot for mistakes. April 13, 2016 ISMP Medication Safety Alert! Acute Care Edition. March 24, 2016;21:1-4. https://psnet.ahrq.gov/issue/do-not-let-depo-medications-be-depot-mistakes Confusion due to look-alike and sound-alike medications are known to contribute to medication err… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60553/psn-pdfJune 03, 2020 - Using social and behavioural science to support COVID- 19 pandemic response. June 3, 2020 Bavel JJV, Baicker K, Boggio PS, et al. Using social and behavioural science to support COVID-19 pandemic response. Nat Hum Behav. 2020;4(5):460-471. doi:10.1038/s41562-020-0884-z. https://psnet.ahrq.gov/issue/using-social-an… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60672/psn-pdfJuly 08, 2020 - The Care We Need July 8, 2020 Washington DC: National Quality Forum; 2020. https://psnet.ahrq.gov/issue/care-we-need This report builds on the legacy of To Err is Human and Crossing the Quality Chasm to outline an approach to improve the US health care system. Five strategic objectives are provided--one of which f… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/847057/psn-pdfApril 05, 2023 - Implement strategies to prevent persistent medication errors and hazards. April 5, 2023 ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4. https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards Medication mistakes are recognized contributors to p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34117/psn-pdfDecember 23, 2016 - Sentinel Event. December 23, 2016 The Joint Commission. https://psnet.ahrq.gov/issue/sentinel-event Since 1998, The Joint Commission has issued sentinel event alerts in response to unexpected incidents involving death or serious physical or psychological injury (or risk thereof). These events are identified as se… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44284/psn-pdfSeptember 09, 2015 - Operating room to intensive care unit handoffs and the risks of patient harm. September 9, 2015 McElroy LM, Collins KM, Koller FL, et al. Operating room to intensive care unit handoffs and the risks of patient harm. Surgery. 2015;158(3):588-594. doi:10.1016/j.surg.2015.03.061. https://psnet.ahrq.gov/issue/operatin… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43916/psn-pdfNovember 30, 2016 - Safer Clinical Systems: Evaluation Findings. November 30, 2016 Dixon-Woods M, Martin G, Tarrant C, et al. London, UK: Health Foundation; December 2014. https://psnet.ahrq.gov/issue/safer-clinical-systems-evaluation-findings This report discusses the results of a United Kingdom initiative exploring how safety strate… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35415/psn-pdfDecember 21, 2008 - Acting Locally: Working in Clinical Microsystems CD- ROM. December 21, 2008 Oakbrook Terrance, IL: Joint Commission Resources; 2005. ISBN 9780866889865. https://psnet.ahrq.gov/issue/acting-locally-working-clinical-microsystems-cd-rom This resource represents a collection of special articles published in the Joint … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60805/psn-pdfAugust 12, 2020 - A blueprint for leadership during COVID-19. August 12, 2020 Rosa WE, Schlak AE, Rushton CH. A blueprint for leadership during COVID-19. Nurs Manage. 2020;51(8):28-34. doi:10.1097/01.numa.0000688940.29231.6f. https://psnet.ahrq.gov/issue/blueprint-leadership-during-covid-19 These authors discuss the effect of the C… -
digital.ahrq.gov/location/usa-tx-dallasJanuary 01, 2023 - USA, TX, Dallas Impact of Health Information Technology Implementation on Diabetes Process and Outcome Measures Description This project evaluated the impact of an electronic health record on the quality of diabetes care as measured by compliance with recommended processes of …
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50641/psn-pdfNovember 06, 2019 - Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. November 6, 2019 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2019. ISBN: 9780309495509. https://psnet.ahrq.gov/issue/taking-action-against-clinician-burnout-systems-a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43827/psn-pdfJanuary 14, 2015 - The surprising way to stay safe in the hospital. January 14, 2015 https://psnet.ahrq.gov/issue/surprising-way-stay-safe-hospital This news article summarizes the results of a survey exploring how patients' perceptions of respect from hospital staff corresponds with the potential for medical error. Recommended strat… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/842432/psn-pdfJanuary 11, 2023 - Medication errors: the year in review: January through December 2021. January 11, 2023 Pharmacy Practice News Special Edition. December 13, 2022: 43-54. https://psnet.ahrq.gov/issue/medication-errors-year-review-january-through-december-2021 Medication errors continue to occur despite long-standing efforts to redu… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47722/psn-pdfJanuary 23, 2019 - Opening the Door to Change. NHS Safety Culture and the Need for Transformation. January 23, 2019 Newcastle upon Tyne, UK: Care Quality Commission; December 2018. https://psnet.ahrq.gov/issue/opening-door-change-nhs-safety-culture-and-need-transformation The term never events was originally coined to describe rare,… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46675/psn-pdfApril 12, 2019 - The hidden curricula of medical education: a scoping review. April 12, 2019 Lawrence C, Mhlaba T, Stewart KA, et al. The Hidden Curricula of Medical Education: A Scoping Review. Acad Med. 2018;93(4):648-656. doi:10.1097/ACM.0000000000002004. https://psnet.ahrq.gov/issue/hidden-curricula-medical-education-scoping-r… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43331/psn-pdfJuly 09, 2014 - Open wide: looking into the safety culture of dental school clinics. July 9, 2014 Ramoni R, Walji MF, Tavares A, et al. Open wide: looking into the safety culture of dental school clinics. J Dent Edu. 2014;78(5):745-756. https://psnet.ahrq.gov/issue/open-wide-looking-safety-culture-dental-school-clinics Researche… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45139/psn-pdfMay 25, 2016 - Alarm management: promoting safety and establishing guidelines. May 25, 2016 Criscitelli T. Alarm Management: Promoting Safety and Establishing Guidelines. AORN J. 2016;103(5):518- 21. doi:10.1016/j.aorn.2016.03.008. https://psnet.ahrq.gov/issue/alarm-management-promoting-safety-and-establishing-guidelines Alarms… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/842775/psn-pdfJanuary 18, 2023 - Safer Together Survey: Advancing Patient and Workforce Safety January 18, 2023 Cambridge, MA: Institute for Healthcare Improvement: January 2023. https://psnet.ahrq.gov/issue/safer-together-survey-advancing-patient-and-workforce-safety The National Steering Committee for Patient Safety (NSC) was formed to engage w… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43654/psn-pdfApril 02, 2015 - Nursing bedside clinical handover—an integrated review of issues and tools. April 2, 2015 Anderson J, Malone L, Shanahan K, et al. Nursing bedside clinical handover - an integrated review of issues and tools. J Clin Nurs. 2015;24(5-6):662-671. doi:10.1111/jocn.12706. https://psnet.ahrq.gov/issue/nursing-bedside-cl…
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